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Evidence-Based Practice Habits: Putting More Sacred Cows Out to Pasture

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 Feature

Evidence-Based Practice
Habits: Putting More
Sacred Cows Out to Pasture
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS
Kathryn T. VonRueden, RN, MS, ACNS-BC
Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN
Jessica Chadwick, RN, MSN, CCNS

For excellence in practice to be the standard for care, critical care nurses must in making decisions about the care
embrace evidence-based practice as the norm. Nurses cannot knowingly continue a of individualized patients.”1 One
clinical practice despite research showing that the practice is not helpful and may even would hope that clinicians would
be harmful to patients. This article is based on 2 presentations on evidence-based strive for this goal in all practice
practice from the American Association for Critical-Care Nurses’ 2009 and 2010 decisions. Unfortunately, philosoph-
National Teaching Institute and addresses 7 practice issues that were selected for 2 ical goals and clinical realities are
reasons. First, they are within the realm of nursing, and a change in practice could
not always congruent. Many practice
improve patient care immediately. Second, these are areas in which the tradition and
decisions that were originally based
the evidence do not agree and practice continues to follow tradition. The topics to
be addressed are (1) Trendelenburg positioning for hypotension, (2) use of rectal
on intuition and tradition have not
tubes to manage fecal incontinence, (3) gastric residual volume and aspiration risk, changed despite compelling evidence
(4) restricted visiting policies, (5) nursing interventions to reduce urinary that change is warranted. The classic
catheter–associated infections, (6) use of cell phones in critical care areas, and (7) example (addressed in the first arti-
accuracy of assessment of body temperature. The related beliefs, current evidence, cle in this series, “Seven Evidence-
and recommendations for practice related to each topic are outlined. (Critical Care Based Practice Habits: Putting Some
Nurse. 2011;31:38-62) Sacred Cows Out to Pasture”2) is the
use of instillation of normal saline
into an endotracheal tube before

I
f we want excellence in prac-
tice to be the standard for care,
critical care nurses must
embrace evidence-based
practice as the norm. We
CEContinuing Education
1. Understand how embracing evidence-
based practice can immediately improve
patient care
2. Recognize 7 areas of clinical practice in
which tradition and the evidence do not
agree
3. Identify recommendations for practice
related to 7 older practice issues or “sacred
cows”
©2011 American Association of Critical-
Care Nurses doi: 10.4037/ccn2011908
cannot knowingly continue a clini-
cal practice despite research that
shows that the practice is not help-
ful and may even be harmful to
the patients we serve. This article
is devoted to putting some clinical
sacred cows out to pasture. It is
based on 2 presentations on
evidence-based practice from the
American Association of Critical-
Care Nurses (AACN) National
Teaching Institute in 2009 and 2010.
The Institute of Medicine
defines evidence-based practice as
“The integration of best research,
clinical expertise, and patient values
suctioning to “loosen secretions.”
Not only does this practice not loosen
secretions, it harms patients and
may be a major contributing factor
to ventilator-associated pneumonia.2
Cutting-edge practice decisions are
commonly based on research or the
best available evidence.3 It is the
older practice habits or “sacred cows”
that are more challenging to change
because the practices are considered
routine and beyond dispute.
The implementation of evidence-
based practice at the bedside takes
commitment and an effective process.
Excellent process models to assist in

38 CriticalCareNurse Vol 31, No. 2, APRIL 2011 www.ccnonline.org

 Table 1 Evidence-based practice Table 2 Systems for evaluating levels of evidence
models
American Association for Critical-Care AACN levels of evidence: 6-level tool for
Iowa model4 Nurses (AACN)13 grading; level A is the strongest evidence
and M is manufacturer’s recommendation
Stetler’s model5 only
Rosswurm and Larrabee’s model6 Centers for Disease Control and Modified HICPAC Categorization Scheme for
Johns Hopkins Nursing model7 Prevention14 Recommendations: 5-scale system
ACE Star Model of Knowledge Society of Critical Care Medicine15 Grades of Recommendation, Assessment,
Transformation8 Development and Evaluation (GRADE System)
was used to evaluate evidence for Surviving
ARCC (Advancing Research and Sepsis Guidelines
Clinical Practice Through Close
Collaboration) model9 American Heart Association16 Used an 8-level scale with 4 classifications
to support recommendations for Basic Life
AHRQ (Agency for Healthcare Support and Advanced Cardiac Life Support
Research and Quality) model10
PARIHS (Promoting Action on
Research Implementation in Health
Services) framework11
implementation is more challeng- could improve patient care immedi-
ing, although not impossible. Once ately. Second, these are areas in which
Colorado model12
the research or evidence is collected, the tradition and the evidence do
it must be evaluated for strength not agree and practice continues to
this goal have been published. and quality by using levels of evi- follow tradition or “sacred cows.”
Table 14-12 lists 9 evidence-based dence. AACN recently published an The topics to be addressed are as
practice models that offer step by updated guide for level of evidence follows:
step approaches and frameworks in Critical Care Nurse.13 Table 2 pro- 1. Trendelenburg positioning for
to use. The typical process pre- vides examples of other evaluation hypotension
scribed by the models is to ask a tools that may be used to assist cli- 2. Use of rectal tubes to manage
clinical question, determine whether nicians in the evaluation of research fecal incontinence
solid evidence exists to support a and evidence in deciding if the evi- 3. Gastric residual volume
particular practice, compare current dence is compelling enough to rec- (GRV) and aspiration risk
practice with the research recom- ommend a change in practice. 4. Restricted visiting policies
mendations, and make appropriate This article addresses 7 practice 5. Nursing interventions to
clinical changes based on the evi- issues that were selected for 2 rea- reduce urinary catheter–associated
dence. Although the process is sons. First, they are within the realm infections
seemingly simple, articulating the of nursing, and a change in practice 6. Use of cell phones in critical
care areas
7. Accuracy of assessment of
Authors
body temperature
Mary Beth Flynn Makic is a research nurse scientist in critical care at the University of The related beliefs, current evidence,
Colorado Hospital and an adjoint assistant professor at the University of Colorado,
Denver, in Aurora, Colorado. and recommendations for practice
Kathryn T. VonRueden is a clinical nurse specialist at the R. Adams Cowley Shock related to each topic are described.
Trauma Center at the University of Maryland Medical Center and an assistant professor
at the University of Maryland School of Nursing in Baltimore.
Trendelenburg Positioning
Carol A. Rauen is an independent clinical nurse specialist and education consultant and
a staff nurse in the emergency department at Outer Banks Hospital in The Outer Banks for Hypotension
of North Carolina. Use of the Trendelenburg position
Jessica Chadwick is a clinical nurse specialist in the emergency department at Inova was originally intended to improve
Fairfax Hospital in Fairfax, Virginia. surgical exposure for abdominal
Corresponding author: Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, 7830 W. 72nd Place, Arvada, CO 80005 procedures. In the late 1800s,
(e-mail: marybeth.makic@uch.edu).
Friedrich Adolf Trendelenburg and
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. one of his students, W. Meyer, first

www.ccnonline.org CriticalCareNurse Vol 31, No. 2, APRIL 2011 39

described the position as a supine
head-down tilt of at least 45º.17 Use
of this position became common
practice in the operating room but
was associated with complications
such as increased central venous
pressure, engorgement of head and
neck veins, increased cerebral spinal
fluid pressure, hypertension, retinal
detachment, impaired oxygenation
and ventilation, gastric secretions
and mucus in the oropharynx caus-
ing aspiration.17 From a practical
aspect, patients placed in the Tren-
delenburg position had to be pre-
vented from sliding head-down off
the table.17 Despite these adverse
outcomes for patients, the practice
of placing patients in the Trendelen-
burg position persists.
Related Beliefs and
Current Evidence
The use of the Trendelenburg
position for hypotension and shock
has been studied for more than 50
years. The proposed physiological
benefit is the shift of intravascular
volume from the lower extremities
and abdomen to the upper part of
the thorax, the heart, and the brain,
thus improving perfusion to heart
and brain. It is estimated that a head-
down position results in a 1.8% dis-
placement of blood volume.18 In the
1960s, however, Weil and Whigham19
reported deleterious effects of using
the Trendelenburg position in animals
and humans. In a hemorrhagic shock
model with rats, mortality and hemo-
dynamic responsiveness were least
favorable in the head-down position;
in humans with hypotensive shock,
blood pressure decreased, lung vol-
umes were compromised, and the
risk of retinal detachment and cere-
bral edema increased.19,20
40 CriticalCareNurse Vol 31, No. 2, APRIL 2011
Cardiovascular response to the
Trendelenburg position appears to
be influenced by the presence of
hypotension and the patient’s ability
to maintain homeostasis. For exam-
ple, in normotensive patients placed
in the Trendelenburg position, little
deleterious hemodynamic effect is
observed.21-23 Even in elderly nor-
motensive patients, who may have
some degree of impairment of vaso-
motor control owing to their age,
no deterioration was noted in car-
diac hemodynamic parameters with
use of the Trendelenburg position.24
Hypotensive patients appear to
have different and more varied car-
diovascular responses to the head-
down position,21,25 and they show no
improvement in blood pressure or
cardiac index.18-21,24-26 As well, key
components of tissue oxygenation
are not improved with the Trende-
lenburg position.27 Most investiga-
tors have concluded that use of the
Trendelenburg position in hypoten-
sive patients has no cardiovascular
benefit.18-21,24-26
Hewer,17 in his 1956 review of
complications of the Trendelenburg
position, discussed the untoward
effects on lung ventilatory mechan-
ics and pulmonary gas exchange.
These effects included reduced vital
capacity even at 20º head-down tilt,
increased work of breathing, and
impaired respiration causing
hypercarbia and hypoxemia. In the
head-down tilt position, the cepha-
lad shift of abdominal contents
increases abdominal pressure,
impairs diaphragmatic function,
and impedes lung expansion. In the
Trendelenburg position, mechanical
impedance of the lung and chest wall
increases and is associated with
increased resistance and decreased
tidal volume.28,29 Lung compliance
can decrease by 20%, PaCO2 increases,
and a mild metabolic acidosis may
develop.26 Ventilation and perfusion
abnormalities, evidenced by an
increase in intrapulmonary shunt-
ing, are also reported in the Trende-
lenburg position.21 Not surprisingly,
as body weight increases, lung
resistance and gas exchange abnor-
malities also increase signifi-
cantly,28,29 which has important
clinical implications for obese criti-
cally ill patients; thus the Trende-
lenburg position should be avoided
in such patients.
Little research is available on
the effect of Trendelenburg position
on intracranial pressure; however,
some agree that it is likely to increase
intracranial pressure because of
the increased central venous pres-
sure,17,24,30-32 but the effects on cere-
bral blood flow are uncertain.
Distension of the internal jugular
vein has been measured and is
increased in head-down tilt, but
internal jugular blood flow is
unchanged. Researchers disagree
on the effect of the Trendelenburg
position on intracranial pressure
and cerebral blood flow, with some
concluding that those factors do
increase,32 while others conclude
that cerebral hemodynamics are
not affected.22 One clinical protocol
that uses Trendelenburg position-
ing for postural drainage of the
lungs in patients with brain injury
originally incorporated criteria
based on changes in intracranial
pressure and cerebral perfusion
pressure33 and now also includes
reduced brain tissue oxygenation
for more precision, as the basis for
returning the patient to supine or
head-up position.
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 In reviewing the literature related
to the physiological effects of the
Trendelenburg position and its use
to treat hypotension and shock, we
encountered a number of limitations
that made it difficult to draw defini-
tive conclusions. Studies were con-
ducted with a variety of populations
(eg, animals, healthy volunteers, or
normotensive patients), sample sizes
were relatively small, the methods
used various degrees of head-down
positioning that ranged from 10º to
30º and the length of time in this
position also varied, and various
end points were measured. Despite
these study limitations, most of the
findings are consistent in that they
show no demonstrated benefit of
the Trendelenburg position for
hypotension or shock. Thus the evi-
dence does not support the use of
head-down tilt for hypotension.
Recommendations for Practice
Trendelenburg position increases
venous return but has little or no
beneficial effect on cardiac output
or blood pressure; the improvement,
if any, is temporary. Pulmonary gas
exchange is impaired in the head-
down tilt position, thus overall oxy-
gen delivery may not improve at all.
As well, the deleterious effects on
lung mechanics and oxygenation are
more exaggerated in obese patients.
Cerebral blood flow and intracra-
nial pressure most likely increase in
the Trendelenburg position, and
the effect may be deleterious in
some patients with brain injuries.
The gravitational movement of
mucus and gastric secretions to the
oropharynx may increase the poten-
tial for aspiration. Table 3 provides
a summary of the evidence and
physiological response to the Tren-
www.ccnonline.org
delenburg posi-
tion.17,21,24,25,27-32 Table 3 Physiological effects of Trendelenburg positioning
in hypotensive patients
Alternatives
to Trendelen- Cardiovascular 21-27
Slight increase in mean arterial pressure
burg position- No increased preload
ing, such as Dilated right ventricle
Decreased right ventricular ejection fraction
passive leg lift, Decreased cardiac output
may provide Increase in systemic vascular resistance
greater benefit 21,26,28,29
Pulmonary
for initial man- Reduced vital capacity
Increased work of breathing
agement of Decreases in PaO2
hypotension or Increases in mechanical impedance of lung and chest wall
prediction of Decreased tidal volume
Decreased lung compliance
fluid respon- Increases in PacO2
siveness with Tissue perfusion 27
minimal or no No change in oxygen delivery
No change in oxygen extraction
untoward No change in oxygen consumption
effect.34,35 Rais-
Gastrointestinal 26,28,29
ing the patient’s Cephalad shift of abdominal contents
legs while keep- Increased abdominal pressure
Impaired diaphragmatic function
ing the head of Impeded lung expansion
the bed hori- 17,24,30-32
Neurological
zontal relative Possible increase in intracranial pressure associated with increase
to the patient’s in central venous pressure
Distention of internal jugular vein
trunk produces
an approximate
volume shift of 150 to 300 mL to Trendelenburg position for patients
the upper part of the thorax. 34,35
with hypotension and/or hypo-
This shift increases aortic volume, volemic shock, and such positioning
may not activate baroreceptors, and is associated with impaired ventila-
avoids risk of gastric aspiration. In tion and oxygenation and may have
25
one study, researchers reported other deleterious effects as just men-
the same adverse cardiovascular tioned. Despite these findings, a
and pulmonary effects for passive survey of critical care nurses about
leg raising as for Trendelenburg practices related to use of Trendelen-
positioning in 18 cardiac surgery burg position conducted in the late
patients. Others have shown that 1990s showed that 80% of the
this maneuver correlates with the respondents would consider using
response to fluid loading and is Trendelenburg positioning to improve
predictive of the need for fluid hypotension.36 Although little new
when a patient’s cardiac output, research has been done since that
stroke volume variation, or blood time, dissemination of information
pressure respond positively to the related to the deleterious effects and
leg lift maneuver. 34,35
lack of benefit of this position has
The evidence, despite the afore- continued.37 A repeat survey would
mentioned limitations, does not be useful to determine if this tradition-
show a demonstrated benefit of the based practice persists.
CriticalCareNurse Vol 31, No. 2, APRIL 2011 41
Use of Rectal Tubes to
Manage Fecal Incontinence
Critically ill patients with incon-
tinence are at high risk for perineal
skin damage, which may also increase
the patient’s risk for pressure ulcera-
tion, secondary dermal injury, and
infection.38-40 Urinary and fecal
incontinence harm the protective
skin barrier through excessive mois-
ture that macerates the skin, com-
promising its defensive functions
for the body. Digestive enzymes and
bacteria inherently found in feces
alter the pH and irritate the skin,
increasing the risk of incontinence-
associated dermatitis and infec-
tion.38,40,41 Nursing management of
critically ill patients with acute diar-
rhea is focused on protecting the
skin as well as containing the diar-
rhea. Research to effectively manage
acute fecal incontinence is limited;
however, evidence is evolving and
best practice guidelines are available
to guide practice.40,42
Related Beliefs and
Current Evidence
Use of rectal tubes to divert fecal
material away from the skin and
into a collection bag, a traditional
approach, is the least safe interven-
tion and the procedure is poorly
defined.40,42,43 Little research exists to
support the use of traditional rectal
tubes (eg, mushroom catheter with
a soft flared tip, urinary catheter
with a balloon); however, these
devices have been used in practice
without clear evidence of the efficacy
and safety of the devices for manage-
ment of fecal incontinence.44
Best practice for the management
of fecal incontinence, to minimize
skin breakdown (ie, incontinence-
associated dermatitis and pressure
42 CriticalCareNurse Vol 31, No. 2, APRIL 2011
Table 4 Possible risk factors to consider in evaluating the cause of acute
fecal incontinence
Type Risk factor
Disease processes45,47 Gastrointestinal and hepatic diseases
Sepsis
Spinal cord injury
Enterotoxins
Medications48 Nonsteroidal anti-inflammatory drugs, antimicrobial agents,
angiotensin-converting enzyme inhibitors, β-blocking
agents, digoxin, lactulose, diuretics
Nutrition49 Enteral tube feeding (consult nutritionist to determine optimal
tube feeding formula and rate to minimize diarrhea)
ulcers), starts with an evaluation of and factors believed to be associ-
the cause of the diarrhea.41,45,46 Begin ated with the diarrhea.
by reviewing the patient’s medical Fecal collectors, also called anal
history, current medications, and bags/pouches, when applied cor-
treatments that may increase gastric rectly are an effective option to
motility or diarrhea. Table 445,47-49 control and contain liquid feces.38,40,57
provides a list of factors to consider Fecal collectors are external devices
in evaluating the etiology of the that consist of a self-adhering skin
patient’s diarrhea. barrier and attached pouch that
Fecal incontinence may be a sec- connects to a drainage bag, provid-
ondary consequence of the patient’s ing a closed system to move liquid
disease or treatment (eg, antibiotics), stool away from the skin. This sys-
so several interventions can be tem is external, providing less risk
implemented to protect the skin to the patient’s rectal sphincter and
before placement of a device in the internal mucosa.40,57 When applied
rectum to divert stool. Nursing correctly, fecal collectors can pre-
interventions to minimize skin vent skin breakdown, minimize
breakdown from fecal incontinence odor, track output accurately,
should be implemented early by decrease exposure to fecal material,
anticipating excessive moisture or minimize caregiver time, enhance
diarrhea on the basis of the patient’s patients’ comfort, and save money.40
current plan of care (Table 5). In a study57 conducted in Europe,
When fecal incontinence is the fecal collector was evaluated in
excessive or incontinence-associated 120 hospitalized patients. The vast
dermatitis is progressing, the use of majority (96%) of nurses reported
fecal containment devices may be that the device preserved perineal
indicated. These devices can be skin integrity, and none of the
divided into 2 categories: fecal patients had adverse skin break-
pouches or indwelling retention down while the device was in place.
devices (tubes). When choosing a Additional benefits of a fecal collec-
fecal containment device to move tor include the following: it can be
effluent away from the perigenital used indefinitely, as needed, to
skin, critical care nurses should manage diarrhea; it will not inter-
assess the patient’s perineal skin fere with gastrointestinal activity as
www.ccnonline.org
 Table 5 Evidence-based management of fecal incontinence
Assessment
Assess patient’s risk for fecal incontinence; anticipate
fecal incontinence associated with disease, medica-
tions, interventions40,42,44,48
Assess the patient for risk of pressure ulcers and
excessive moisture and prolonged immobility by
using a valid and reliable risk assessment tool39,46
Assess skin during the cleansing process
Cleanse the skin with no-rinse cleanser, moisturize
and protect the skin with each episode of inconti-
nence38,42,45,50
Assess the need for moisture absorbing incontinence
pad to wick effluent away from the skin42,44
Assess the need for air flow near the skin and advanced
bed redistribution technology (follow hospital proto-
col for advanced bed therapy); avoid excessive
linen52,53
Assess patient’s mobility and encourage toileting
Assess nutritional needs and evaluate tolerance of
tube feeding
Evaluate skin for fungal infection associated with
fecal incontinence38,51
Assess skin, development of incontinence-associated
dermatitis, as well as frequency and consistency of
stool to determine need for a fecal containment
device42,44,57-62
Assess resolution of cause of diarrhea, changes in diar-
rhea flow, consistency, and skin condition to deter-
mine need for ongoing fecal containment device57-62
Evidence-based intervention
Protect the skin with moisture barrier products in anticipation of diarrhea
Complete a risk assessment daily and with a change in patient’s condition39;
implement interventions based on specific findings on risk assessment
Using soap and water with a washcloth is not optimal for basic skin care40,42
Soaps are frequently alkaline and further damage the protective acidic mantle
of the skin40,42
Washcloths may increase friction and damage fragile skin40,42
No-rinse bathing/perineal cleansing wipes are pH balanced, gentle on the skin,
and enhance removal of organic debris38,42,45,51
Research shows that no-rinse bathing products are effective in reducing
bacteria on the skin50
Incontinence overhydrates skin but removes essential oils that need to be
replenished by applying moisturizers and moisture barrier products38,40,41,51
Use a single moisture-absorbing or wicking underpad under the patient to pull
effluent/moisture and liquid stool away from skin38,51,54-56
Avoid the use of diapers, especially with immobile patients, as diapers trap
fecal material against the skin and exacerbate skin damage40,51
Limit layers of linens beneath the patient; multiple layers of linen can inhibit
bed redistribution technology and air flow from reaching the skin39,52,53
Excessive linen entraps moisture, creates crinkles and pressure, and may
increase the risk of pressure ulcers52,53
Obtain bedside commodes and implement a toileting schedule to minimize
incontinence epidose47
Consider consult a nutritionist for diarrhea believe to be related to tube
feeding49
Fungal infection may be managed effectively with the application of topical
antifungal barrier creams
Consider fecal collectors or bowel-management system42,44,57-62
Remove fecal containment devices when liquid stool resolves57-62

diarrhea resolves; and it will not
compromise the rectal sphincter
and mucosa.
The nasopharyngeal airway
(nasal trumpet) has been studied
as a device to contain fecal inconti-
nence in critically ill patients.58
With this method, a soft nasopha-
ryngeal airway is inserted into the
rectum and connected to a drainage
collection system. Research on this
method of fecal containment is
limited; however, initial results
indicate that the device was well tol-
erated by patients, was practical for
nurses, and effectively contained
fecal matter without untoward
effects for patients.47
Traditional rectal tubes (eg,
mushroom catheter with a soft flared
tip, urinary catheter with a balloon)
for management of liquid stool are
considered the least safe approach
for management of diarrhea.38,40,44
These devices are inserted into the
rectal vault and held in place by
inflating the balloon or mushroom
tip of the catheter. Table 6 outlines
the advantages and disadvantages
of these traditional devices for fecal
diversion. The use of balloon tubes
or mushroom catheters is an adap-
tation of the device for fecal con-
tainment, and because of the lack
of evidence to support their safe
and effective use and the availability
of other fecal containment systems,
these devices should be avoided in
current practice.38,40,42,44

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Table 6 Advantages and disadvantages of traditional rectal tubes (mushroom
catheter with soft flared tip, urinary catheter with a balloon)a
Advantages
Diverts liquid stool away from skin
a Based on evidence from Gray et al,38,41 Wishin et al,40 Petterson,41 Beitz,42 Beekman et al,44 and Grogan and
Kramer.58
Bowel management systems
(BMSs), also called fecal manage-
ment systems, are medical device
systems designed to direct, collect,
and contain liquid stool in immobile
patients. Several BMSs are commer-
cially available and approved by the
Food and Drug Administration for
up to 29 days of use for manage-
ment of liquid stool.42,59 BMSs have
unique characteristics and specific
insertion techniques (readers are
referred to device instructions for
insertion); however, the indications
and contraindications are similar
across device manufacturers. BMSs
are soft flexible catheters with con-
tainment drainage systems. The bal-
loon used to inflate and secure the
catheter within the rectum is soft
and conforms to the rectal vault,
reducing the risk of anorectal
trauma.42,44 When used properly,
the BMS contains liquid stool,
allows accurate measurement of out-
put, decreases health care providers’
exposure to body fluids, and may
protect perirectal skin or denuded
perigenital skin or wounds, thus
enhancing healing.38,42,44,59 Several
studies have been conducted to
evaluate the effectiveness and safety
44 CriticalCareNurse Vol 31, No. 2, APRIL 2011
Disadvantages
Fecal material must be liquid to pass through tube
Tubes may leak and create perirectal skin damage
As diarrhea resolves, the tube may block stool
Ballooned devices require strict periodic deflation
to prevent rectal mucosal injury
Injury of anal sphincter is not easily assessed
Duration for use of the device has not been
established
of using BMSs for diarrhea man-
agement. Padmanabhan and col-
leagues60 evaluated the outcomes of
42 patients in whom a BMS was used
to contain diarrhea. The researchers
found that the device did not harm
the rectal mucosa (by performing
endoscopy at baseline and after
removal of the BMS), perigenital
skin condition improved in 92% of
the patients, and the health care
providers reported that the system
was easy to manage. Keshava et al61
conducted a prospective study of
inpatients admitted for burn man-
agement or to the geriatric unit.
Twenty-two patients with diarrhea
were managed with a BMS. Mean
duration of therapy was 14 days.
Proctoscopy after tube removal
showed normal rectal tissue, and
the health care providers in that
study also reported ease of use of
the device. In a quality improve-
ment study,62 researchers found that
the combination of interventions to
prevent pressure ulcers along with
the introduction of a BSM in their
critical care unit resulted in a signif-
icant decrease in the frequency of
pressure ulcers. Although a direct
correlation cannot be made between
the BMS and the reduction in fre-
quency of pressure ulcers, use of a
BMS to contain diarrhea and man-
age excessive moisture combined
with strategies for preventing pres-
sure ulcers resulted in good out-
comes for patients. Critical care
nurses should assess the need for a
BMS to manage severe diarrhea with
the goal of removing the devices as
soon as possible.
Recommendations for Practice
Management of fecal inconti-
nence to minimize incontinence-
associated dermatitis and pressure
ulcers begins with an accurate nurs-
ing assessment of the patient’s risk
for fecal incontinence, early proac-
tive perineal skin hygiene to protect
skin and minimize irritation, and
critical evaluation of when an exter-
nal fecal containment device or
BMS is needed. Evidence-based
interventions (Table 5) should be
used in the care of patients with
fecal incontinence.
Gastric Residual Volume
and Aspiration Risk
Little evidence supports the use
of measurement of GRV to assess
gastric emptying and tolerance of
tube feeding, yet the practice of
assessing GRV while a patient is
receiving tube feeding persists.63,64
Several assumptions may exist
related to the assessment of GRV.65-67
First, the nurse may assume that
GRV provides information about
normal and abnormal gastric
emptying. Second, the nurse may
think that an elevated GRV indi-
cates delayed gastric emptying
and intolerance of enteral tube
feeding. Third, a high GRV may be
believed to result in a higher risk
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for aspiration that may lead to aspi-
ration pneumonia. In fact, the evi-
dence has demonstrated that
checking a GRV in enterally fed
patients does not improve patients’
outcome or reduce complications.65-71
So why do we continue to check
GRV, and what evidence supports
continuing this practice?
Related Beliefs and
Current Evidence
The lack of definition of how to
measure GRV accurately creates a
challenge in clinical practice.68,69
Most guidelines suggest the use of
a large-volume syringe (60 mL) for
aspiration of fluid because smaller
syringes may collapse the gastric
tube.64,66 However, use of a syringe
may not consistently result in aspi-
ration of the total volume of fluid
present in the stomach.70,73 GRV is
more easily obtained from large-bore
gastric tubes (eg, 14F-16F diameter)
than small-bore gastric tubes (8F-12F
diameter). Metheny and colleagues74
reported that larger GRVs were
detected 2 to 3 times more often
with large-bore gastric tubes than
with gastric tubes with a smaller
bore. Other variables that affect
measurement accuracy include the
position of the tube port in the gas-
tric antrum, the patient’s position,
and the tube’s location near the
gastroesophageal junction.68,72 GRV
with enteral feeding tubes placed
beyond the pylorus is questionable
because of the small size of these
tubes and the physiological proper-
ties of the small bowel to continu-
ously propel gastric contents
forward, unlike the gastric antrum.66
Similarly, if a gastric tube migrates
near the gastroesophageal junction,
GRV will be negligible in most
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cases.69 Frequent monitoring (eg,
every 4 hours) of GRV is indicated
as one method to monitor gastric
tube location. After obtaining
radiographic confirmation of accu-
rate placement of a gastric tube,
observing the appearance and
changes in the volume of gastric
aspirate may assist in monitoring
for migration of the gastric tube.75
Another debate about the moni-
toring and interpretation of GRV
is defining what constitutes a high
gastric residual.64,66-68 Under normal
conditions, saliva and gastric flu-
ids accumulate at approximately
188 mL/h in the stomach; thus any
order to withhold tube feedings for
a GRV less than 188 mL is inappro-
priate.64 Published reports vary in
providing guidance for what consti-
tutes a high gastric residual, rang-
ing from 150 mL to 500 mL of
aspirate.64,65,66,68,71,72 Best evidence
suggests that a single high GRV
should be monitored for the fol-
lowing hour, but enteral feeding
should not be ceased or withheld
for an isolated GRV greater than
250 mL.65,68 Serial hourly elevated
GRVs greater than 250 mL may
require withholding enteral feeding
for an hour in conjunction with
evaluation for prokinetic agents to
promote gastric motility and assess-
ment of possible causes for decreased
gastric tolerance, including a
change in the patient’s acuity.64,66,68
Elevation of GRV is anticipated to
be greatest in the first few days of
enteral feeding. Questions remain
unanswered on when to stop check-
ing GRV to evaluate tolerance of
enteral feeding.
The greatest concern with with-
holding enteral feeding because of
GRV or concern for aspiration is
CriticalCareNurse Vol 31, No. 2, APRIL 2011 47
underfeeding critically ill patients.
Elpern et al76 studied enteral feed-
ings in an intensive care unit and
found that tube feedings were fre-
quently withheld or stopped for
procedures, changes in patients’
body positions, high GRV, and diar-
rhea. Of the patients studied, a mean
of 64% of the patients had their
nutrition goals met, and the mean
length of interruptions for enteral
feeding was 5.23 hours per patient
per day. McClave and colleagues67
reported similar results. In their
study, only 14% of the patients
received 90% goal feeding within 72
hours of starting enteral feeding.
Reasons reported in this study for
stopping enteral feeding included the
following: placement of the patient
supine for procedures or nursing
care, high GRV, and preprocedure
protocols. Little evidence supports
the practice of stopping or withhold-
ing tube feeding to reposition patients
or when placing patients supine
briefly for routine care.67 Current
evidence suggests reducing the time
that enteral feedings are withheld
before procedures to minimize
underfeeding critically ill patients.66,67
The primary belief associated
with high GRV is risk for aspiration
by the patient. Aspiration has been
demonstrated with GRVs from 5 mL
to 500 mL.67 Aspiration is often clin-
ically silent. No reliable clinical
marker has been found for risk of
aspiration, including GRV assess-
ment.65,68,72,76 Risk for aspiration is
increased with hemodynamic insta-
bility, increased acuity or critical
illness (eg, sepsis), altered level of
consciousness, neurological com-
promise, sedation, and mechanical
ventilation. Interventions to mini-
mize aspiration include elevating
the head of bed more than 30º, initi-
ating continuous enteral feedings,
using medications to promote gas-
tric motility, and consideration of
postpyloric feeding.64-66,68,69 Ongoing
evaluation of patients’ tolerance of
enteral feeding is also necessary to
interpret GRV. Signs of intolerance
may include bloating, abdominal
pain, nausea, vomiting, and emesis.
Implementing and adhering to
enteral feeding protocols (Figure 1)
to minimize unnecessary cessation
of enteral feeding is needed to opti-
mize nutrition in critically ill patients.
Isolated high GRVs should be
reassessed in subsequent hours and
accepting higher GRVs in the absence
of signs of intolerance is necessary
in clinical practice.65 Increasing GRV
may be a symptom of another under-
lying problem manifesting itself as
delayed gastric emptying.68 If serial
measurements of GRV remain ele-
vated, the cause should be explored
rather than simply withholding
enteral feeding, which is likely to
result in underfeeding of critically
ill patients.67,68,76
Recommendations for Practice
Critically ill patients are at risk
of aspiration because of severity of
illness and interventions that com-
promise the gag reflex. Variables that
increase a patient’s risk for aspiration
include sedation, mechanical venti-
lation, neurological compromise/
altered level of consciousness, hemo-
dynamic instability, and sepsis. Pre-
venting aspiration begins with
accurate and ongoing assessment of
feeding tube placement (see AACN
Practice Alert: Verification of Feed-
ing Tube Placement75), maintaining
the elevation of the head of the
patient’s bed at greater than 30º, and
48 CriticalCareNurse Vol 31, No. 2, APRIL 2011
evaluating the patient’s tolerance of
tube feeding.65,66,71 Assessment of
GRV is not an effective method of
determining aspiration risk.64-68,70,74
Table 7 outlines the evidence for
GRV monitoring and interventions
to prevent aspiration. Implement-
ing an evidence-based enteral feed-
ing protocol inclusive of increased
acceptance of higher GRV along
with physical assessment of the
patient’s tolerance and intolerance
of tube feeding will maximize the
delivery of adequate nutrition to
critically ill patients.
Restricted Visiting Policies:
A Thing of the Past?
Restriction of visitors for hospi-
talized patients has been practiced
for many decades. For example, in
the late 1800s, restricted visiting
hours were implemented in some
hospitals and applied to nonpaying
patients to establish order in gen-
eral wards. In the early 1900s, pay-
ing patients were permitted to have
visitors anytime, anywhere. The
advent of intensive care units dur-
ing the 1960s saw restricted visiting
implemented to protect patients
and family from exhaustion caused
by too many visitors.77 The spec-
trum of “visiting” can be thought of
as a continuum (Figure 2). Current
attitudes and practices in critical
care units span this continuum.78,79
Related Beliefs and
Current Evidence
Evaluation of the evidence
related to friends and family visiting
patients reflects both practitioner
preferences and a focus on patient-
and family-centered care.80 A land-
mark study by Molter81 in 1979
began to change the attitudes and
practices of nurses with regards to
visitation. Using the Critical Care
Family Needs Inventory, the pri-
mary needs of families of critically
ill patients were identified to be
related to the need for information,
support, comfort, assurance, and
proximity to the patient. A subse-
quent study reported that in addi-
tion to these needs, families also
have a need to be present in order
to provide reassurance and support
to the patient and to protect the
patient.82
The needs, preferences, and
stressors of critically ill patients also
have been examined.83 In a survey
of critical care patients, 40 stressors
were identified; number 4 was
“missing your spouse,” and number
8 was “only seeing family and
friends for a few minutes each
day.”83(p100) These investigators con-
cluded that although some visiting
restrictions were appropriate, the
policies should be modified and
flexibility should be exercised.
Perceived barriers to liberalized
visiting and the rationales for restrict-
ing visiting in critical care units are
multifactorial (Table 8).80,84-86 These
concerns were distilled into 3 major
groups in a recent study87 of 171
hospitals, of which 32% had unre-
stricted, open visiting. The cate-
gories are (1) Space: interference
with patients right to privacy and
confidentiality in instance of shared
rooms; (2) Conflict: crowding and
traffic, hindering the ability to care
for patients and loss of structure
and authority for nurses; and (3)
Burden: to provide care for both
patients and their visitors.
In the past several decades,
many studies have been conducted
related to the psychological and
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 ENTERAL NUTRITION (EN) FEEDING GUIDELINE
UNIVERSITY OF COLORADO
EN may be contraindicated with: Mesenteric ischemia, SBO, paralytic ileus, or GI fistula
H OSPITAL
Goals: 1) Initiate EN within 24-48 hours of admission*♦ 2) Deliver >90% of required calories on a daily basis.

Elevate HOB to 30-45°.♦ Initiate Osmolite 1.2 (unless formula otherwise specified) at 25 mL/hour.

YES NO
1st residual > Maximum GRV? Q4H residual > Maximum 1) Refeed gastric residual.
1) Refeed residual to maximum 400 mL; GRV (350 mL♦)? 2) Continue feeds at same rate if at goal
discard excess rate; ↑feeds by 25 mL every 4 hours
2) Go to PROKINETIC GUIDE (Box A). if not at goal rate.
3) Continue feeds at same rate.
2nd consecutive residual > Maximum GRV?
1) Continue below
MAXIMUM GASTRIC RESIDUAL VOLUME (GRV): 350 mL
(unless otherwise specified by physician)
1) Refeed gastric residual to maximum
400 mL; discard excess
2) Hold feeds; recheck residual in 1 hour. BOX A: PROKINETIC GUIDE
1) Initiate metoclopramide*#♦ 10 mg IV Q6H (5 mg Q6H if↓ renal function)
2) Continue metoclopramide if already receiving.
NO 3) Do not stop feeds; continue ‘Enteral Nutrition Feeding Guideline’.
4) If residuals > Maximum GRV after 4 doses of metoclopramide, consider
Rechecked residual > Maximum GRV? combination prokinetic therapy and/or small-bowel feeding tube. Refer to
SMALL-BOWEL FEEDING GUIDE (BOX B).
YES
BOX B: SMALL-BOWEL FEEDING GUIDE
1) Discard gastric residual. 1) Placement: Insert postpyloric feeding tube*#♦
2)↓feed rate by 50% (ie, 100→50 mL) to a 2) Feed resumption: Following confirmation of postpyloric tip position,
minimum of 25 mL / hour. resume feeds at previous rate,↑feeds by 25 mL Q4H if not at goal rate.
3) Do not stop feeds. 3) Aspiration prevention (In sedated/intubated patients only):
4) If residuals > Maximum GRV Insert a large-bore nasogastric tube (NG) for gastric decompression.*#
after 4 doses of IV metoclopramide consider Clamp NG and discard gastric residuals Q4H (or place on straight drainage).
combination prokinetic therapy and/or small- 4) Tube maintenance: Flush postpyloric tube with 10-30 mL water
bowel feeding tube. Refer to SMALL- every 4 hours
BOWEL FEEDING GUIDE (Box B) If tube clogs,*# instill pancreatic enzyme mixture (8000 units crushed
pancrelipase; 650 mg crushed sodium bicarbonate; 5-15 mL water) into
postpyloric tube per policy. Resume feeds at previous rate,
↑feeds by 25 mL Q4H if not at goal rate. Notify physician after 3
Refer to “Enteral Nutrition unsuccessful attempts.
Problem Solving Guide” on UCH 5) If EN contraindications (above) or significant N/V or abdominal
Critical Care QI Committee distention develop, notify physician and consider stopping small-
Web site for further EN practice bowel tube feeds.
guidelines and recommendations.

* Unless contraindicated # Requires MD order

♦ Evidence-based recommendation; all other information opinion-based.

Developed by: J Greenwood (Vancouver General Hospital) in collaboration with the CCCCPGC 7/2003.
Revised by: B Fulmer, L Kassel, R Saucier, G Vigue. P Wischmeyer (University of Colorado Hospital) 7/2009.

Figure 1 University of Colorado Hospital’s protocol for enteral nutrition.

Abbreviations: CCCCPGC, Critical Care Clinical Practice Guidelines Committee; EN, enteral nutrition; GI, gastrointestinal; GRV, gastric residual volume; HOB, head of
bed; IV, intravenous; MD, physician; N/V, nausea/vomiting; Q4H, every 4 hours; Q5H, every 5 hours; QI, quality improvement; SBO, small-bowel obstruction; UCH,
University of Colorado Hospital.
Reprinted with permission of the University of Colorado Hospital, Aurora, Colorado.

www.ccnonline.org CriticalCareNurse Vol 31, No. 2, APRIL 2011 49

 Table 7 Best evidence for monitoring enteral feeding
Follow an evidence-based enteral feeding protocol65,68
Verify correct placement of enteral feeding tubes on a radiograph, with ongoing monitoring every 4 hours and as needed75
When possible, use a large-bore gastric tube for enteral feeding and evaluate gastric residual volume (GRV) the first few days after
initiating enteral feeding with a 60-mL syringe68
Maintain head of bed at 30° elevation or higher
Monitor trends in GRV; repeatedly high GRV (ie, >1 high GRV; high GRV is defined as a range between 250 and 500 mL) may require
additional interventions65-68; consider use of promotility/prokinetic agents64-66,71
Follow institutional protocol for reinstilling gastric aspirate; to reduce tube occlusions if GRV is reinstilled, increase routine water
flushes of the feeding tube64; if aspirate is discarded, record volume in output measurements
Evaluate patient for signs of intolerance to tube feeding (eg, bloating, abdominal pain, nausea, vomiting, and emesis)
Consider postpyloric feeding in patients with consistently high GRV65,68

led
ntrol
co ed ive ure
d d
nt act xib
le
lus uct icte
en tie ntr r str
Op Pa Co Fle Inc St Re

Figure 2 Spectrum of visiting policies.

minutes, on average 3 or 4 times

Table 8 Perceived barriers to liberalized visitinga
Barriers related to patients
Adverse physiological effects
Hinder patients from getting
sufficient sleep or rest
Interrupt and interfere with
the provision of care
a Based on evidence from Sims and Miracle,80 Fernandez et al,84 Petterson,85 and Roll.86
physiological effects of visitors on
patients and staff. If patients’ wishes
regarding visiting are to be consid-
ered, nonstressful and flexible visiting
Barriers related to clinicians
Uncomfortable providing care or conducting proce-
dures in front of family members
Create a sense of loss of control or structure during
emergency situations
Feel intimidated
Concerns regarding litigation
Uncomfortable interacting with family members
Tax limited health care provider resources
Worries that family members might ask multiple
questions
Increased stress, physical and mental exhaustion of
family and friends thus becoming more of a
burden and requiring more time of the staff
Concerns for maintaining the privacy of other patients
Concerns for safety of self and other patients because
of a fear of increased gang violence
is of primary importance. In one
study,88 researchers reported that
patients preferred usually no more
than 3 visitors, for about 35 to 55
per day and that visitors offered
reassurance, comfort, and calming.
Regarding the physiological
effects of visitors on patients,
research results indicate that visi-
tors have no effect on patients’
blood pressure or heart rate.89-92 In
a randomized study91 of a coronary
care population, patients having a
visitor at a frequency and length of
time of the patient’s choosing had
fewer cardiovascular complications
than did patients whose visitors
were permitted to visit only twice a
day. The lower complication rate
may be due to reduced anxiety and
lower cortisol levels associated with
time spent with their families and
visitors.91
Similarly, no physiological
rationale exists for restricting
visitors of patients with brain
injuries. No deleterious effects on

50 CriticalCareNurse Vol 31, No. 2, APRIL 2011 www.ccnonline.org

neurological status related to visit-
ing have been reported, and some
patients experience a reduced
intracranial pressure associated
with visits by loved ones.93,94 Patients
with traumatic brain injury were
monitored during family conversa-
tions at the bedside. These patients
experienced no change in intracra-
nial pressure; systolic, diastolic, and
mean blood pressure; heart rate; res-
piratory rate; arterial saturation; or
restlessness when listening to family
voices.95
The beneficial effects of liberal
visiting policies on patients’ families
are well supported. These effects
include reduced family stress and
burden; lower anxiety96; family’s
ability to serve as a historian, pro-
tector, coach, facilitator, and volun-
tary caregiver97; providing basic care
such as baths, mouth care, or mas-
sage improves respect, collabora-
tion, perceived support of health
care providers, and scores on a
family-centered care survey.98
Another mechanism that sup-
ports flexible visiting and increases
families’ participation in care of
loved ones is including patients’
families in daily rounds with the
health care team.99,100 Benefits of
daily family rounds include the fol-
lowing: decrease in unexpected calls
or disruptions of physician team
rounds; structured time for clinicians
to focus on one patient with that
patient’s family; increased participa-
tion and active, constructive engage-
ment with the staff; identification of
families who may benefit from more
formal care conferences; and greater
satisfaction of patients and their
families with the critical care experi-
ence.99 The total time commitment
for nurses and physicians on a
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Table 9 Recommendations for family visiting from the American College of
Critical Care Medicinea
Open visitation to provide flexibility for patients and their families is permitted and
established on a case-by-case basis
A visitation schedule that is determined collaboratively between patient, patient’s family,
and nurse, taking into account the best interest of the patient
Whenever possible, family presence and participation is encouraged at rounds, and
family presence is permitted during resuscitation
Family participation in patients’ care is encouraged as much as the patient’s condition
and the family’s comfort level will allow
Clean and immunized pets are allowed to visit in the intensive care unit
a Based on evidence from Davidson et al.103
Table 10 Practice implications for family visiting
Assess and consider the needs of the patient and the patient’s family
Support flexible visiting hours through the development and implementation of less
restrictive and more collaborative visiting protocols
Include patient’s desires and signage regarding accepting visitors in the protocols
Develop family presence on rounds program
Encourage family members to participate in patient care as much as possible when
they are visiting
Address staff security concerns in visiting protocols
Educate patients’ families about the intensive care unit and visiting protocols, and have
the family identify a key spokesperson/contact
Educate health care providers about evidence that supports open, flexible family visiting
12-bed neurotrauma unit was 1 Recommendations for Practice
hour or less per day.99 Daily rounds Critical care nurses, in their
and early and routine family meet- roles as advocates for patients and
ings can provide an opportunity to their families, are in a pivotal posi-
assess the family and foster commu- tion to support patient- and family-
nication, understanding, and collab- centered care, which includes open,
oration between the family and flexible visiting. Table 10 lists
health care providers.101,102 evidence-based practice implications.
The American College of Critical The Joint Commission recently
Care Medicine charged an interdis- acknowledged the importance of
ciplinary group of physicians, family-centered care and visitation
nurses, and a clinical pharmacist to in providing support to patients. As
develop evidence-based guidelines of 2011, the Patient Rights Standard
for support of family-centered care. regarding hospitals’ respect, protec-
The authors reviewed numerous tion, and promotion of patients’
studies and made 43 recommenda- rights (RI.01.01.01) will have a new
tions for practice.103 Table 9103 out- element of performance: “The hos-
lines the key recommendations pital allows a family member, friend
relating to family visiting. or other individual to be present
CriticalCareNurse Vol 31, No. 2, APRIL 2011 51

Table a11 Evidence-based guidelines for placement of indwelling urinary
catheters
Clear Indications
Urinary obstruction/retention
Alteration in blood pressure or volume status
Need accurate measurements of fluid input and output but
the patient cannot use urinal or bedpan
Emergency surgery
Major trauma
Urologic procedures
Bladder irrigation
Management of stage III or greater pressure ulcer
Comfort care for terminally ill patients
a Based
on evidence from Hooton et al,106 Greene et al,108 Gould et al,109 and Saint et al.110
with the patient for emotional sup-
port during the course of stay.”104
This new element should provide
further impetus to develop and
implement flexible visiting protocols
in the critical care areas. Perhaps the
endorsement of open, flexible visit-
ing is best stated by McAdam and
colleagues: “families need to be rec-
ognized for contributions they
make and invited ‘into the world
and work’ of ICUs.”97(p1100)
Nursing Interventions to
Prevent Catheter-Associated
Urinary Tract Infections
Improving patients’ outcomes
often requires rethinking practice,
systems, and the “why” behind com-
mon interventions and devices used
in the management of critically ill
patients.105 The insertion of a urinary
catheter device is one example in
which reexamining the evidence and
nursing care associated provides an
opportunity to improved patients’
outcomes. Catheter-associated uri-
nary tract infections (CaUTIs) are
the most common hospital-acquired
infection, accounting for almost 40%
52 CriticalCareNurse Vol 31, No. 2, APRIL 2011
Contraindications
Fall prevention
Routine urine specimens
Staff/patient request
Excoriated skin
Altered mental status
of all nosocomial infections. An esti-
mated 80% of CaUTIs are associated
with indwelling urinary catheters.106-109
Related Beliefs and
Current Evidence
Obviously the easiest way to pre-
vent a CaUTI is to avoid insertion of
the device. When an indwelling uri-
nary catheter is needed to monitor
a patient, however, prevention of
CaUTIs begins by understanding
the clinical indication for the device
and removing the catheter when the
clinical condition has resolved. The
primary use of a urinary catheter is
for close monitoring of a patient’s
hemodynamics and fluid balance,
surgical procedures, and urologic
diseases.106,108,109 The literature sug-
gests that urinary catheters are not
indicated to prevent falls, for man-
agement of patients with altered
mental status, to avoid skin excori-
ation, or to obtain urine speci-
mens.106,108,110 Table 11 provides a list
of clear indications for insertion of
urinary catheters as well as a list of
conditions in which a catheter is
not indicated.
Delirium in critically ill patients,
especially older hospitalized
patients, is an increasing concern
that is associated with poor out-
comes for patients.111 Multiple fac-
tors contribute to delirium, and
indwelling urinary catheters have
been identified as a specific risk
variable.112 Bladder catheters can
act as an informal restraint, limit-
ing patients’ movement, especially
when the clinical indication for the
device is no longer evident.113 The
presence of an indwelling urinary
catheter in a delirious patient
increases the risk of falls and the
risk for traumatic dislodgment of
the catheter and subsequent urethral
trauma. Early removal of urinary
catheter devices and implementa-
tion of normal toileting practices
(eg, bedside commode, offering
urinal), frequent rounds, use of
moisture wicking underpads, reori-
entation with specific questions
concerning elimination needs, and
review of medications that may
increase urgency/need to void are
important nursing interventions in
the management of patients with
acute delirium.114,115 Similarly,
indwelling urinary catheters are not
indicated as a primary intervention
to manage moisture-related skin
breakdown.106,108,109 Skin care inter-
ventions to manage incontinence,
such as moisture barrier creams
and moisture wicking products,
should be explored before insertion
of a urinary catheter. In the pres-
ence of stage III or IV pressure
ulcers in the perineal region, an
indwelling catheter may be neces-
sary to assist with wound healing.106
The need for a bladder catheter
with concomitant thoracic patient-
controlled epidural analgesia is
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another area for opportunity to
reexamine practice and reduce
CaUTIs. Research results indicate
that an indwelling urinary catheter
can be safely removed in conjunc-
tion with thoracic patient-controlled
analgesia therapy.116,117 Early removal
of the catheter in these studies was
associated with earlier ambulation,
shorter length of hospitalization,
lower CaUTI rate, and lower inci-
dence of postoperative urinary
retention.117,118 Once a patient with a
thoracic patient-controlled epidural
for analgesia is hemodynamically
stable, the evidence suggests that
removal of the bladder catheter
should be considered.116-118
Knowing the clear indication for
the bladder catheter and minimiz-
ing catheter duration are important
first steps in preventing CaUTIs.
Exploring options for elimination
when an indication for an indwelling
catheter is not clear is essential to
reduce unnecessary insertion of
devices. Daily reevaluation of the
need for the indwelling device, dis-
cussing a discontinue order with the
prescribing provider, and prompt
removal are also important steps to
reduce the risk for infection.
Many critically ill patients need
an indwelling urinary catheter to
monitor fluid balance and hemody-
namic status. In the event that a
bladder catheter is necessary, nurs-
ing interventions in the management
of the bladder catheter may assist in
the reduction of CaUTIs. Table 12
summarizes current evidence to help
prevent CaUTIs.
Placing an indwelling urinary
catheter device is a fundamental
skill taught to all nurses. Opinions
vary on whether to use sterile or
aseptic technique for the placement
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Table 12 Recommendations for practice to reduce occurrence of catheter-
associated urinary tract infections
Know the indication for the indwelling urinary catheter. Use automatic stop orders and
reminders to request an order to remove the device when the indication is resolved.119
Use aseptic technique with sterile equipment to insert the device.106,108,109 Aseptic tech-
nique is most often defined as the use of sterile gloves, mask, sterile barriers, perineal
washing using an antiseptic cleanser, and no-touch insertion technique.120
Perform routine meatal care with soap and water during daily bathing.106,108,109 Use of
antiseptic cleansers, creams, lotions, or ointments is no better than perineal care
provided with soap and water.106,118,120-122 Antiseptic agents may irritate the urethral
meatus and increase the risk of infection.120
Maintain a closed system106,108,109 with the drainage bag below the level of the bladder.106,108-110,123
Use a catheter securement device.124,125
Explore elimination options to prevent reinsertion (eg, bladder scanner, bedside com-
mode, urinal, moisture wicking underpads, nursing rounds).120-127
of the device to reduce CaUTIs.108,118 (eg, cleansing of the meatal surface
Part of the challenge is defining during daily bathing) is all that is
sterile and aseptic technique within needed to maintain an indwelling
the clinical context of the skill.121 urinary catheter.106,108,109
Willson and colleagues120 conducted Securing the indwelling urinary
a review of the literature and found catheter is strongly recommended
that aseptic technique for urinary in the guidelines of the Centers for
catheter placement was most often Disease Control and Prevention.109
defined as the use of sterile gloves, Research evidence describing the
mask, sterile barriers, perineal effectiveness of securing a urinary
washing using an antiseptic cleanser, catheter and the prevention of
and no-touch insertion technique. CaUTIs is limited.109,120,122,124,125 The
Current recommendations suggest practice of securing a catheter is
that maintaining aseptic technique primarily based on clinical experi-
and using sterile equipment while ence and expert opinion (ie, Society
inserting the catheter are both of Urologic Nurses and Associates),125
important elements to minimize which suggests that securing the
infection.106,108,109 urinary catheter prevents urethral
Part of urinary catheter care trauma, erosion, and inadvertent
includes care of the urethral meatus. removal and increases patients’
Research on meatal care with anti- comfort.124 A number of devices for
septic cleansers, creams, lotions, or securing catheters are available, and
ointments found them to be to be many experts recommend applying
no better than routine perineal care the device to the upper thigh in
provided with soap and water at women and the abdomen in men.124,125
reducing CaUTIs.106,118,120-122,124 Some Maintaining a closed system to
evidence suggests that antiseptic prevent CaUTIs is supported by
agents may actually increase the current guidelines.106,108-110,120 Catheter
risk of infection by irritating the and drainage systems are designed
urethral meatus.120 Current guide- with prepackaged seals to prevent
lines suggest “routine hygiene” inadvertent disconnection and act
CriticalCareNurse Vol 31, No. 2, APRIL 2011 53
as a physical barrier to the migration
of microbes.120 If drainage system
seals are broken in practice, a sys-
tems analysis of the most common
barriers to maintaining the closed
system should be explored. For
example, if the emergency depart-
ment uses bladder catheter systems
without metered drainage collection
devices, the critical care nurse may
need to break the system to obtain
a metered urometer for hourly
monitoring. System analysis could
suggest a change to all metered
catheter kits, streamlining products
and enhancing compliance with
evidence-based practice guidelines.
Maintaining the collection bag below
the level of the bladder is another
important practice recommenda-
tion, as it minimizes reflux into the
catheter itself and prevents retro-
grade flow of urine.106,108,109 Emptying
the drainage bag frequently and
before all patient transports is a
simple and effective strategy to
reduce CaUTIs. Resist the habit of
placing the drainage bag between
the patient’s legs during transport.
All health care providers need to
work together to keep the drainage
bag below the bladder.123
The effectiveness of ultrasound
bladder scanners as a strategy to
reduce CaUTIs is not well studied,
and further research is needed to
demonstrate effectiveness of this
monitoring intervention. However,
the clinical benefits of bladder scan-
ners include effective diagnosis of
urinary retention, reduction of
unnecessary intermittent catheteri-
zations, enhanced comfort for
patients, and cost savings associ-
ated with inappropriate catheteriza-
tions.126,127 Ultrasound bladder
technology provides an assessment
54 CriticalCareNurse Vol 31, No. 2, APRIL 2011
tool to assist with early removal of
indwelling invasive urinary catheters.
The evidence to support the use
of urinary catheters coated with an
antimicrobial agent (silver alloy or
antibiotic) to reduce CaUTIs is
inconclusive.106,128 The clinical evi-
dence defining the safety, efficacy,
and appropriate use of silver-coated
urinary catheters in randomized
controlled trials supports the use of
such devices in reducing CaUTI in
patients with short catheter dura-
tions128; however, the magnitude of
reduction in infection did not differ
significantly from uncoated catheters
in all trials.127 Current guidelines do
not recommend routine use of
coated catheters in all hospitalized
patients to reduce CaUTI.106,108,109,128-130
In a recent systematic review
and meta-analysis, Meddings et al119
found that urinary catheter
reminders and stop orders appeared
to reduce CaUTI rates. Implement-
ing systems that provide physicians
and nurses with routine reminders
to evaluate the need for the bladder
catheter reduced the rate of CaUTIs
by 56% (P=.005). Automatic stop
orders in this study reduced the
rate of CaUTIs by 41% (P<.001).
Overall use of urinary catheters was
also found to be decreased in sev-
eral of the studies analyzed in that
meta-analysis.
Recommendations for Practice
Indwelling urinary catheters are
commonly used devices in the man-
agement of critically ill patients, and
evidence-based nursing interventions
are needed to prevent infection.
One intervention, in isolation, is
less effective than a bundle of inter-
ventions in preventing CaUTIs.110
Focusing nursing care on the basis
of best-practice interventions is
necessary to minimize critically ill
patients’ risk for developing a
CaUTI. Using a multidisciplinary
approach to prevent CaUTIs is the
most effective method of improv-
ing patients’ outcomes. Several pro-
grams are available to assist
organizations in developing CaUTI
prevention programs (eg, from the
Association for Professionals in
Infection Control and Epidemiology
Inc108). Using these programs along
with frequent publication of the
teams’ efforts in reducing CaUTIs
will support the momentum of this
change. Ensuring that management
of indwelling urinary catheters is
based on best evidence is essential
to improving patients’ outcomes.
Use of Cell Phones in
Critical Care Areas
Cellular phone technology is
used every day by millions of people
in all walks of life, businesses, and
professions. Cell phones have
become an integral tool of the med-
ical community as a means of fast
and convenient communication,
yet cell phone restrictions remain
in critical care units. What is the
science behind the restrictions?
Related Beliefs and
Current Evidence
In many hospitals, cell phones
are used as a primary means of
communication with medical staff
in case of emergency and have
become an essential clinical resource
for accessing information in the
care of critically ill patients.131 In a
recent survey,132 70% of medical
personnel indicated that they carry
their mobile devices to areas such as
the operating room and critical care
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units despite strict restrictions, and
95% ranked their ability to use
mobile phone technology in the
hospital as very important or impor-
tant. Despite the vast array of uses
and popularity in the health care
arena, mobile technology remains
banned in many hospitals nation-
wide. These bans originated in the
era of analog telephone devices and
have remained in place despite
numerous technological advances.
Current policies often state that cel-
lular telephones must be turned
completely off when arriving in the
hospital or in the critical care areas,
a difficult policy to enforce. These
rules are based on the premise that
cellular devices when in the “on”
position transmit detrimental elec-
tromagnetic interference. The exam-
ination of effects of electromagnetic
interference are outlined in Table 13.
Policies regarding patient safety
concerns related to electromagnetic
interference have been focused pri-
marily on the distance between the
cellular device and medical equip-
ment. This has also been the focal
point of clinical studies related to
electromagnetic interference.133,134
Mechanical ventilators have been
identified as one of the most critical
pieces of medical equipment and
therefore have been the most com-
monly examined biomedical tech-
nology. Most studies define cell
phone interference as anything from
a change in screen appearance, to
false alarms, to complete shutdown
of the ventilator.133,135-138 In several
studies,135,136 researchers reported
that the maximum distance between
the cellular devices and various ven-
tilators that would cause interfer-
ence with the ventilator function
was 100 cm. In another study,137
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Table 13 Electromagnetic interference: effects on medical technology
Electromagnetic radiation is emitted intentionally or unintentionally by devices that
generate electromagnetic fields, and such radiation may affect the functioning of
medical devices.133
The reception of electromagnetic interference by biomedical technologies used
throughout the hospital is a cause for concerns about patient safety.
The effect of electromagnetic interference on biomedical technology is based on 3 key
variables133,134
• Interference is associated with the distance between the cellular device and the
medical equipment.
• The degree of shielding that the medical device has against electromagnetic
interference.
• Amount of electromagnetic interference is closely linked to the characteristics of
the cellular phone.
Testing of effects of electromagnetic interference on biomedical devices in clinical
studies most commonly involves testing the maximum level of frequency required to
accept or receive a phone call and the radiation emitted toward the biomedical equip-
ment and the corresponding reaction.
Research is needed to explore
The degree of shielding built into different pieces of medical equipment to protect
against electromagnetic interference, with rigorous evaluation of each brand of
equipment used within the hospital.131
Evaluation of characteristics of cellular devices and range of interference, minimal to
maximal radiation release and proximity to cellular tower,131 and the location of cell
phone use in the hospital.
researchers identified 9 hazardous phone is less than 100 cm from the
incidents involving ventilators that device.137,138,140
occurred at a median distance of 3 Based on analysis of the evi-
cm (range, 0.1-300 cm) from cellular dence, new guidelines must be
device to ventilator. Only one of developed that would change cur-
those incidents occurred when the rent hospitalwide bans of cell phone
cell phone was more than 100 cm technology. Current evidence sup-
away from the ventilator, and that port the Medicines and Healthcare
incident was linked to older genera- Products Regulatory Agency140 rec-
tion cellular technology.137 ommendations of 2004, which
Other biomedical equipment state that a total ban is not neces-
that has been examined for the effect sary. To address the concern of dis-
of electromagnetic interference tance between the cellular device
includes devices such as pulse oxime- and biomedical equipment, the
ters, cardiac monitors, carbon diox- notion of a “1-meter rule” should
ide detectors, and defibrillators.138,139 be established. Using that rule,
For those items, it was determined medical personnel as well as patients
that the maximum distance for and family members would be able
interference was only 20 cm away. to use their mobile technology as
The evidence suggests that the range long as they were more than 1 m
of electromagnetic interference with away from critical care equipment.
various types of medical equipment This practice provides extra safety,
is 0 to 300 cm (9 feet).137-139 However, in that interference is most likely to
clinically significant electromag- occur when the cell phone is within
netic interference with biomedical 3 cm to 20 cm (1 to 8 in) of biomed-
devices can occur when a cellular ical devices.138,139
CriticalCareNurse Vol 31, No. 2, APRIL 2011 55
 Another recommendation is to
create specific, well-marked “cell
phone areas” in convenient locations
throughout the hospital that afford
use of cell phones without concern
for electromagnetic interference. In
a recent study,141 creation of rooms
where cell phone use was acceptable
on an adolescent inpatient unit
increased satisfaction among patients.
Adolescents rely heavily on their cell
phones to remain connected to fam-
ily and friends while hospitalized.
Once allowed to go to a cell phone–
friendly room, the patients were able
to remain compliant with hospital
rules while still staying in touch with
their “outside lives.” Revision of cur-
rent policies related to cell phone
use that are based on research will
be useful in increasing satisfaction
of patients, patients’ families, and
health care professionals.
Recommendations for Practice
Hospital policies that ban use
of cellular phone devices are not
only impractical to enforce, they
also exclude a key tool that is used
as a vital source of information for
health care providers. A review of
current evidence indicates that this
position is outdated and unneces-
sary. Less restrictive guidelines such
as the 1-meter rule and/or cell
phone–friendly areas should be
applied to new policies. Revising
current policies can increase satis-
faction of patients, visitors, and
staff. Hospitals and the biotechnol-
ogy industry will also benefit from
more extensive testing of their
equipment for sensitivity to electro-
magnetic interference, as there is
tremendous variability between
hospitals and the biotechnical
equipment used in each.
56 CriticalCareNurse Vol 31, No. 2, APRIL 2011
Accuracy of
Assessment Table 14 Temperature measurement sites and devices
of Body Sites for measurement of
core temperature143,144,146,148
Temperature
Distal part of esophagus
Accurate
Nasopharynx
measurement of
body tempera- Tympanic membrane
ture is essential
in the manage-
ment of critically
ill patients. Unfortunately an accu-
rate, noninvasive method to meas-
ure core temperature has yet to be
established.142-144 Understanding the
differences in body temperatures
measured at various body sites,
technology limitations, and “user
error” is important when evaluating
body temperature values in criti-
cally ill patients.
Related Beliefs and
Current Evidence
In practice, assumptions may
be made about the accuracy of the
temperature measurement device
and the relationship of the tempera-
ture measured to the core tempera-
ture. Physiological temperature can
be defined as central (core) and
peripheral temperatures. Central
temperature is a stable temperature
reflective of 60% of the body mass
and is tightly regulated by the
body.144-146 Near core temperatures,
peripheral temperatures, may vary
over time or be influenced by
extreme environmental and physio-
logical variables,143 but under normal
conditions correlate closely with
core temperature.144 The most accu-
rate core temperature is obtained
via a pulmonary artery catheter;
although infrequently used, this
method is considered the “gold
standard.”143,144,146-149 Table 14 provides
the evidence on which sites are used
Sites for measurement of
near core temperature144,149
Mouth
Bladder
Rectum
Temporal artery
Axilla
for core and near-core temperature
measurements.
To interpret and track trends in
body temperature correctly, clini-
cians should consider site-specific
temperature as well as device limita-
tions and accuracy in obtaining the
temperature. Researchers comparing
body temperature measured with
various devices and methods with
core temperatures considered the
temperature device to be accurate if
the mean difference in temperatures
obtained was ±0.3ºC and to be pre-
cise if the standard deviation was
from 0.3ºC to 0.5ºC.144,147,149,150 A mean
difference in temperature greater
than 0.5ºC between devices would
represent a clinically significant dif-
ference.147 It is unclear whether criti-
cal care nurses in clinical practice
differentiate the accepted difference
in temperature measurements
obtained with different devices and
how the clinical interpretation of
the measurement plays into subse-
quent clinical decisions.
Errors in accurate temperature
measurement are most often associ-
ated with choice of measurement
site, instrument-related errors, and
operator error.143,144,148 Temperature
monitoring devices require accurate
application to provide intended
measurement data; however, user
error causes erroneous temperature
measurements.143,147 Device limitations
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 Table 15 Summary of different temperature modes, variation from core temperature, clinical advantages and disadvantagesa

Site of temperature measurement Variation from core temperature Best practice: advantages (+) and disadvantages (–)
Pulmonary artery Reference standard + True core temperature
– Highly invasive
Oral <0.4°C + Ease of use
+ Oxygen up to 6 L and endotracheal tube do not influence
accuracy146,149,155
+ Research has shown that administration of warmed gases
and oxygen through an endotracheal tube does not cause
significantly different oral temperature compared with core
temperature153,155
– Accurate placement of probe in the mouth (posterior sublingual
pocket) is necessary for correct temperature reading143,146,147,149
– May be influenced by fluids and tachypnea156
Esophagus <0.1°C + Correlates closely with pulmonary artery temperature.144,147,150
Optimal placement requires the esophageal temperature
probe to be positioned at the point of maximal heart tones
(left atrium) in the distal part of the esophagus144,146 and at an
insertion depth between 32 and 38 cm.150
+ Minimal lag time for temperature measurement144,147
– Temperature fluctuates according to depth of probe; accu-
rate placement is key150
Bladder <0.2°C + Easy to perform with urinary catheterization; low risk of
dislocation
+ Temperature is accurate during dates of increased diuresis154
– Accuracy of temperature influenced by low urine flow144,150
– Lag time estimated up to 20 minutes during therapeutic
hypothermia interventions150
Rectum <0.3°C + Easy to perform
– Invasive; placed in rectal vault; may be expelled with intes-
tinal motility
– Lag time estimated up to 15 minutes144,150
– Accuracy of readings influenced by stool in the rectum
Temporal artery <0.4° C + Minimally invasive temperature closely correlated with core
temperature
+ Temporal artery is not significantly affected by thermoregu-
latory changes; therefore perfusion should be stable in most
conditions and closely reflect core temperature.144,156,157
– Current research has provided mixed results as to accuracy
of this device in different practice settings, patient popula-
tions, and physiological conditions.
– Diaphoresis may influence accuracy of temperature readings.
– Accuracy of temperature measurement procedure required
for correct temperature reading from the forehead and
behind the ear.156,158
Tympanic membrane Not recommended for tempera- – Tested in multiple populations of patients; however, user
ture monitoring143,144,147,149,151,159 error and patient’s anatomy reduce accuracy of temperature
obtained.143,144,147-149
a Based on evidence from Hooper and Andrews,143 Sessler,144 Crawford et al,145 Torossian,146 Forbes et al,147 Bridges and Thomas,148 Hooper et al,149 Polderman and
Herold,150 O’Grady et al,151 Exacon Scientific,152 Konopad et al,153 and Fallis.154

include the range of temperatures in
which the thermometer has been
tested. Few devices have been rigor-
ously tested in all populations of
patients and during extremes in
temperature (hypothermic and hyper-
thermic states), yet multiple devices
are used in these extremes of body
temperature to assess patients. When
sensing temperature “lag” in patients
with therapeutic hypothermia, both
the temperature-measuring device
and the physiological temperature
site are variables that should be
considered with clinical trending of

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temperature and subsequent thera-
peutic interventions.150
In some practice settings, the
measurement of a newly elevated
temperature triggers an automatic
order set that includes many tests
that are costly and disruptive to the
patient.151 Knowing which tempera-
ture measurement technique is best
to assess a patient may minimize
the frequency of obtaining inaccu-
rate temperature readings. Also, it is
important to remember that tem-
peratures obtained from 2 different
body sites should not correlate exactly
but should be “close in range” (ie,
<0.5ºC apart). Table 15 provides a
summary of different temperature
measurement modes, their advan-
tages and disadvantages, and the
mean variation in temperature from
the core temperature measured in
the pulmonary artery.143-145,148,150-153
Recommendations for Practice
Despite how commonly body
temperature is assessed in the man-
agement of critically ill patients, the
best noninvasive device to measure
core temperature accurately remains
to be developed.142,145 Although no
ideal device has been developed yet,
critical care nurses can make good
clinical decisions based on the type
of device used to measure the tem-
perature, the patient’s characteris-
tics, and the user’s competence.
Understanding device limitations
and knowing that temperatures
obtained from 2 devices should dif-
fer by less than 0.5ºC are important
To learn more about evidence-based practice,
read “Evidence-Based Practice, Rule-Following,
and Nursing Expertise” in the American Journal
of Critical Care, 2009;18:479-482. Available
at www.ajcconline.org.
58 CriticalCareNurse Vol 31, No. 2, APRIL 2011
to clinical interpretation of temper-
None reported.
ature measurement and assessment.
References
Optimally, the same method of tem-
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parameters in a patient with a new
fever should guide clinical decisions,
not a single temperature reading.148,151
Closing: Moving Evidence
Into Practice
As Thomas Paine said in 1776,
“A long habit of not thinking a thing
wrong, gives it a superficial appear-
ance of being right.”160 The practices
reviewed in this article are all within
the domain of nursing, and it is
important as nurses that we chal-
lenge tradition and “habits in our
nursing practice.” As we continue
to perfect the art of nursing, we
must also remember the science of
nursing. Science is dynamic and ever
changing. Clinical practices should
be based on evidence whenever
possible. The challenge is in getting
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encouraging and empowering the
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critical care nurses are instrumental
to the process of examining and
implementing the evidence in prac-
tice, putting sacred cows out to pas-
ture. CCN
Now that you’ve read the article, create or contribute
to an online discussion about this topic using eLetters.
Just visit www.ccnonline.org and click “Respond to
This Article” in either the full-text or PDF view of
the article.
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CriticalCareNurse Vol 31, No. 2, APRIL 2011 61
CE Test Test ID C1123: Evidence-Based Practice Habits: Putting Sacred Cows Out to Pasture
Learning objectives: 1. Understand how embracing evidence-based practice can immediately improve patient care 2. Recognize 7 areas of clinical practice in
which tradition and the evidence do not agree 3. Identify recommendations for practice related to 7 older practice issues or “sacred cows”

1. What is a physiological effect of Trendelenburg positioning in 7. What is considered a physiological effect of visitors on hospitalized
hypotensive patients? patients?
a. Increased right ventricular ejection fraction a. Decreased cortisol levels
b. Increased lung compliance b. Increased systolic blood pressure
c. Increased abdominal pressure c. Decreased arterial saturation
d. Increased tidal volume d. Increased intracranial pressure

2. What is a potential benefit of passive leg lift for initial management of 8. What is an appropriate indication for urinary catheter insertion?
hypotension? a. Fall prevention
a. Decreased aortic volume b. Routine urine specimen collection
b. Decreased aspiration risk c. Skin excoriation management
c. Baroreceptor activation d. Comfort care for terminally ill patients
d. Upper thorax volume shift of 500 mL
9. What is considered a best practice to prevent catheter-associated
3. What is the least safe intervention to divert fecal material away from skin? urinary tract infections in hospitalized patients?
a. Fecal pouches a. Minimizing catheter duration
b. Traditional rectal tubes b. Using silver alloy-coated urinary catheters
c. Bowel management systems c. Routinely using ultrasound bladder scanners
d. Rectally-inserted nasopharyngeal airway d. Performing daily urinary meatal cleansing with antiseptic agents

4. What is an evidence-based intervention to manage fecal incontinence? 10. The “1-meter rule” provides extra safety because electromagnetic
a. Cleanse the skin with a no-rinse cleanser interference is most likely to occur within what distance of biomed-
b. Use soap and water with a washcloth for basic skin care ical devices?
c. Use diapers for immobile patients a. 3 to 20 mm c. 3 to 20 m
d. Use multiple layers of bed linen to pull liquid stool away from skin b. 3 to 20 cm d. 3 to 20 km

5. What has evidence demonstrated about gastric residual volume 11. What site of temperature measurement most closely correlates
(GRV) measurement in enterally fed patients? with pulmonary artery temperature?
a. Elevated GRV indicates enteral tube feeding intolerance. a. Bladder
b. Elevated GRV indicates delayed gastric emptying. b. Rectum
c. A high GRV increases aspiration pneumonia risk. c. Temporal artery
d. Measuring GRV does not improve patient outcomes. d. Esophagus

6. What is considered a best practice for enteral tube feedings?
a. Withhold enteral feeding for an isolated GRV greater than 250 mL
b. Use a 30 mL syringe to aspirate GRV
c. Consider postpyloric feeding in patients with consistently high GRV
d. Discontinue tube feedings to reposition patients
12. What is correct about monitoring urinary bladder temperature?
a. It has a high risk of dislocation.
b. Temperature is not accurate during periods of increased diuresis.
c. Estimated lag time is up to 20 minutes during therapeutic hypothermia.
d. Its accuracy is uninfluenced by low urine output.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C1123 Form expires: April 1, 2013 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP: Category A
Test writer: Denise Hayes, RN, MSN, CRNP
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www.ccnonline.org This method of CE is effective RN Lic. 1/St RN Lic. 2/St
(“CE Articles in this issue”) for this content K K
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The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
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